Download Deato_Stroke_Prevention-3 - AANN Northern Illinois Chapter

Mary Christine Deato, MSN RN, AGPCNP-BC, SCRN
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Identify individuals at risk for stroke
Understand the role and use of stroke
assessment tools
Identifying learning needs and appropriate
teaching materials
Identify modifiable and non-modifiable risk
factors
Identify stroke prevention strategies based
on clinical practice guidelines
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80% of strokes may be prevented by
identifying risk factors and reducing personal
risk
A SCRN must recognize risk factors and
implement primary and secondary
prevention strategies to minimize stroke
Nurses are the forefront of stroke prevention
and inpatient quality improvement programs!
ISCHEMIC STROKE
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Age: risk doubles for each decade after 55
Sex: more prevalent in males
 Men with higher stroke incident per age group
than women except in the age group 35-44
▪ OCP and pregnancy
 Cardiovascular mortality in men contribute to the
higher incidence of stroke in older women
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Race and Ethnicity
 US: Blacks and Hispanics have higher incidence and
mortality rates
 ARIC Study: Blacks 38% higher risk
▪ HTN, obesity and diabetes
 SHS Study: American Indians have higher incidence
compare to whites and blacks
▪ HTN, smoking, poor glucose control
 Genetics: family hx increases risk by 30%
▪ HTN, diabetes, hyperlipidemia
▪ Coagulopathies increases risk of venous thrombosis
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Hypertension
 Lowering BP - most important in preventing ischemic
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and hemorrhagic stroke
HTN is increasing due to increasing obesity
Lack of diagnosis and inadequate treatment common
in minorities and elderly
The higher the BP, the greater the stroke risk
SBP increases with age
2/3 persons age 65 have HTN
Tx of HTN lowers incidence 35-44%
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Tx of pre-HTN (BP: 120-130/80-89)
 Weight loss
 Smoking cessation
 Heart healthy diet
▪ Sodium <2300 mg/day
 Calcium, potassium, and magnesium
 Exercise 30 min/day or at least several days per
week
 Limit alcohol
▪ 2 drinks for men, 1 women
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Cigarette Smoking
 Doubles risk of ischemic stroke and contributes to 12
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14% of all stroke deaths
Acute effects on thrombus formation in narrowed
arteries
Chronic effects to development of atherosclerosis
Increases HR, mean BP and cardiac index
Decreases arterial distensibility
OCP and smoking increases risk 7.2 times
Second hand smoke risk due to the
development of atherosclerosis
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Cigarette Smoking Tx Options
 Include willingness, motivation, social support
 Cold turkey may have withdrawal symptoms but
is a one step free process
 Nicotine fading, changing brands to lower level
every week for 3 weeks then stop on the 4th week
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Cigarette Smoking Tx Options
 Nicotine replacement – gum, patch lozenge,
inhaler, nasal spray
 Prescription meds come with black box warning
due to mental health problems
▪ Zyban reduces withdrawal symptoms
▪ Chantix block nicotine receptors in the brain and
reduces pleasurable effects
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Patients fall into three groups:
 Those willing to quit receive intervention to help
quit
 Those unwilling to quit receive intervention to
increase motivation to quit
 Those who recently quit receive intervention to
prevent relapse
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Diabetes
 Has increased by 61% since 1990 and 33% in people with
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Hx of ischemic stroke
DM is a risk factor for first stroke
Increase risk ranging from 1.8 to 6 fold
All ages but mostly before 55 yrs in blacks and before 65
yrs in whites
Increase in DM parallels increase in obesity
Dx: fasting glucose >126 or A1C >6.5
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DM Tx
 Reduces cardio and stroke risk by 20%
 Lowering A1C <7% appears to reduce risk in
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younger newly diagnosed
Moderate weight loss improves glycemic control
and reduces CV risk
24% reduction in stroke with use of statin
Tight BP decreases risk by 44%
Use of antiplatelet if appropriate
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Dyslipidemia
 33.5% US adults have high LDL and 1 out of 3 has
their cholesterol under control
 Elevated total cholesterol increases risk of heart
disease two-fold
 Race, ethnicity, gender have a role in
hyperlipidemia development
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Dyslipidemia
 Tx to reduce LDL show reduction in coronary heart disease risk
by 25%-45% over 5 years
 For every 39 mg/dl decrease in LDL there is a 21% risk reduction
 Statins with benefits in patients with CAD
▪ Those with prior coronary events showed stroke rate reduction by 2732%
 Niacin tx showed 24% reduction in CVA/TIA
 Gemfibrozil showed to raise HDL, lower triglycerides and LDL
 Reduce saturated fats, increase plants, fiber, omega 3, weight
management, increase physical activity, smoking cessation
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Atrial Fibrillation (AF)
 Causes more than 75,000 stroke per year in the 2.6
million Americans who have AF
 Age increases prevalence, 5% 70 yrs and older
 Four to five fold increase risk of stroke
 AF strokes usually large and disabling
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Risk classifications
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Clinical predictor for stroke in patients with AF
▪ CHADS2
▪ CHA2DS2-VASc
▪ HAS-BLED
▪ Defines bleeding risk prior to starting anticoagulants
Score
Risk Criteria
1 point
CHF
1
HTN
1
Age >75 years
1
DM
2
Stroke/TIA
Score
Risk
Recommendation
0
Low
ASA 81-325 mg daily
1
Intermediate ASA 81-325 mg daily or
Warfarin (INR 2-3) based
on patient’s preference
2 or
more
High
Warfarin (INR2-3), unless
there are reasons to avoid
Annual Stroke Risk
 0=1.9%
 1=2.8%
 2=4%
 3=5.9%
 4=8.5%
 5=12.5%
 6=18.2%
Score
CHA2DS2-VASc
Score
HAS-BLED
1
1
CHF
1
1 or 2
HTN (SBP >160 mm Hg)
1
1
Age ≥75 y
1
1
Bleeding tendency/predisposition
2
1
Stroke/TIA/TE
1
1 or 2
Elderly (age >65 y/o)
1
1
Aged 65 to 74 y
HTN
DM
Vascular disease (prior MI,
PAD, or aortic plaque)
Sex (female)
Abnormal renal and liver function
(1 point each)
Labile INRs (if on warfarin)
Drugs or alcohol (1 point each)
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AF Tx
 Prevent thromboembolism, correct rhythm problems
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and rate control
CHADS2 > 2= anticoagulation
CHA2 DS2 – VASc > 2 = anticoagulation
Increased risk of bleeding while on warfarin if >75
years, concomitant antiplatelets, uncontrolled HTN,
and high INR
Monitor for symptoms of AF, cardiac monitoring,
medications, diet, labs, alcohol, smoking, exercise,
hydration
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Asymptomatic Carotid Artery Stenosis
 Includes 1% of Americans: 60-99% narrowing of carotid artery
 Ipsilateral stroke risk 3% for 60-74% blockage, 3.7% for 75-94%
blockage 2.9 % for 95-99% blockage and 1.9% with complete
occlusion
 Risk include high cholesterol
▪
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Diet high in saturated and trans fats
Smoking
Overweight
Lack of physical activity
HTN
Metabolic syndrome
Age: men before 75 yrs, women after 75 yrs
▪ Genetics
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Tx of carotid disease
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Low fat low salt diet
Healthy weight
Exercise
Smoking cessation
Limit alcohol
Medications
CEA (carotid endarterectomy) if symptomatic
with 70% stenosis
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Postmenopausal Hormone Tx
 During menopause women developed cardiovascular risks
which include abdominal obesity, increase body
cholesterol, and LDL with decrease HDL
 Risk of stroke double
 Tx of estrogen plus progestin or estrogen increases stroke
risk
 Transdermal estrogen safer
▪ 0.25% mg of estrogen = 35% more likely to develop stroke, 1.25mg
= 63%, 0.30 mg not at increased risk
 AHA states hormone tx should not be used for heart
disease or stroke prevention
▪ If tx necessary lowest dose and transdermal tx
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Oral Contraceptive (OC)
 Can put women at risk higher risk if older than 35, smoke,
HTN, DM, migraines, hypercholesterolemia, obese , or
prothrombin mutations such as factor V Leiden
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Tx:
 BP measurement prior to starting OC, control BP,
cholesterol, and glucose, no smoking, weight loss and
physical activity
 Diet and nutrition can help BP control
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Risk include – excess salt
Low potassium
Increased alcohol
Blacks more sensitive to these risks on BP
▪ DASH diet
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Physical inactivity contributes to stroke risk
 48% of US adults do not meet physical activity
guidelines
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Tx of physical activity on stroke risk
 Moderately active = 20% lower stroke risk
 High active = 27% lower stroke risk
 Improves heart functioning, lipid profile
 Lowers BP
 In creases insulin sensitivity
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Obesity and Fat Distribution
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37% adults in the US are obese
Blacks highest followed by Hispanics
Medical cost for obesity $147 billion
Obesity associated with ischemic stroke
Abdominal fat stronger predictor of stroke risk.
▪ Obesity =waist circumference >102 cm or 40 inches in men and 88cm
or >35 inches in women
 Intra-abdominal pressure associated with thrombophlebitis,
lower limb circulatory stasis, and HTN
 Obesity associated HTN leads to increase vascular
resistance, cardiac output, blood volume and sodium
retention
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Obesity and Fat Distribution
 BMI >25 associated with increased
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cholesterol and triglycerides and
decreased HDL
ECH BMI unit >22 increases DM risk by 25%
Weight gain of 5-8 kg increases CAD by 25%
Obesity alters the cardiac structure and increases risk of CHF
Hypokalemia most common electrolyte disturbance with
obesity that can lead to cardiac arrhythmias or myocardial
repolarization because of increase fatty acid levels
Obstructive sleep apnea increases as BMI increases
Tx for weight loss includes diet, physical activity, behavior
modification, pharmacologic therapy and bariatric surgery
 Migraine Headache
▪ Plus visual aura, odds for ischemic stroke are 1.5 greater
for women according to University of Maryland Study
▪ If smoking and OC use, risk increases 7-fold
▪ Migraine frequency and duration associated with risk
 Pathophysiology of migraine with aura related to
stroke
▪ Reduced blood flow
▪ Decreased blood volume
▪ Cortical spreading depression
▪ Short lasting depolarization that alters brain activity involving
changes in neural and vascular function
▪ Increased platelet activation and platelet-leukocyte
aggregation
▪ Possible relationship between PFO and migraine
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Migraine Headache Tx:
 No data that will reduce risk of first stroke
 Biofeedback, relaxation, cognitive behavioral therapy,
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medication
Prevention included AEDs, antidepressants, antiHTNs
Alternative therapies like yoga, massage,
acupuncture, chiropractic, herbal supplements
Avoid food and drink triggers, stress, fatigue, skipped
meals, lack of sleep, vasodilator use, fluctuating
hormone levels
Regular exercise
Sleep-Disordered Breathing (SDB) prevalence ranges 3%7% and is under diagnosed. Risk factors include increased
age, male, obesity, family history, menopause, smoking,
alcohol
 Snoring is a marker for SDB and increase stroke risk by
leading to:
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HTN
Heart disease
Cardiac arrhythmias
Decreased cerebral blood flow
Hypercoagulability
Inflammation
Paradoxical embolism in pts with PFO
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Snoring
 Relationship between SDB and HTN
 Odds of developing HTN increased by 1% for each apnea event
per hour of sleep; and if there was a decrease in oxygen
saturation, the odds increased by 13%
 Tx:
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CPAP
BIPAP
Surgery
Oral device
Avoid alcohol
Smoking
Nasal sprays
Raise head of bed
Position on side
HEMORRHAGIC STROKE: INTRACEREBRAL
HEMORRHAGE (ICH)
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Age: risk increases every 10 yrs
 Blacks: 5X increased risk at age 45 but 1/3 risk at 85
years
 Sex: 3x higher risk in men
 Race: Blacks, Mexicans, and Asians
 Genetics: Apolipoprotein E gene, versions E2 and E4
(very low LDL) have been associated with lobar ICH
through the promotion of cerebral amyloid
angiopathy (CAA)
▪ Inherited clotting factor disorders, Factor V, VII, X, XI and XIII
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CAA – amyloid-beta deposition in the brain, damages
blood vessels causing microhemorrhages
AB causes vasculature to become brittle and fragile,
impairs regulation of cerebral blood flow, disrupts blood
brain barrier and causes inflammation
Small or medium blood vessels
Lobar ICH
Usually 55 years
Increased risk of ICH with anticoagulation tx
PROGRES Study showed lowering BP even if not
hypertensive protected against CAA related ICH
Avoid statins if recent CAA related ICH
Tramiprosate may delay or inhibit progression by binding
soluble AB and interfering with amyloid cascade
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Use of sympathomimetic drugs
 Rx: cathecholamines, epinephrine,
norepinephrine, dopamine
 Non-Rx: cold remedies, weight loss drugs
containing ephedrine or phenylpropanolamine
 Illegal substances: cocaine, amphetamines,
methampetamine, ecstacy
▪ Increase heart rate
▪ Blood vessel contraction
▪ Reduces digestive secretions
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Hemorrhagic transformation of ischemic
stroke: mechanisms
 Vascular injury
 Reperfusion
 Disruption of blood brain barrier
 Altered permeability
 Attributed to thrombolysis if bleeding occurs 24-
36 hours post tPA
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Hemorrhagic transformation of ischemic stroke :
risk factors
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Increased age
Stroke severity
HTN
Hyperglycemia
Early computed tomography changes
Large baseline diffusion lesion volume on MRI
Goal: prevent by careful screening, following tPA
guidelines and controlling BP and blood glucose
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Reperfusion Syndrome – increased in ipsilateral
cerebral blood flow above brain tissue needs
 Thrombolytic tx
 Complications of CEA
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Risk Factors:
 Post op-HTN
 High grade stenosis with poor collateral flow
 Recent contralateral CEA <3months
 Intraoperative distal carotid pressure <40 mmHg
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Prevention
 Use of transcranial doppler
 Vasodilators, ACE inhibitors, and calcium channel
blockers less preferred
 Agents that do not cause excessive vasodilation
preferred i.e. labetalol, nicardipine
 Smoking and diabetes are weak risk factors for
ICH except if a diabetic smokes and uses OCPs
▪ Risk increases by 3.7x
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Hypercholesterolemia
 Possibly protective
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Low cholesterol may contribute to fragile vasculature
MRFIT trial
 Mortality risk showed 3-fold increase in men with total
cholesterol of 160 compared with higher levels
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Rotterdam Scan Study
 Showed pts with the highest level of triglycerides had the
lowest rate of deep and infratentorial bleeds
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SPARCL trial
 Found increase risk of recurrent ICH with high dose of
atorvastatin use
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Not sufficient data to restrict use of statin
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85 % due to ruptured aneurysm (aSAH)
9.7-14.5% per 100,000 but may be higher
because 12-15% die prior to hospital
Sex: women 1.6x higher risk but posterior
communicating aneurysms are more likely to
rupture in men
Age: increases with age, mean age 50 yrs
 Anterior circulation aneurysms more likely to
rupture younger than 55 years
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Race: blacks 2.1x higher
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Genetics
 11x higher
 5-20% have family Hx of aneurysm
 3-7 fold increase risk if first degree relative, but
second degree same as the general population
 First SAH at earlier age
 More likely to have large or multiple
 Genetic disease: autosomal dominant, polycystic
kidney disease, Ehler’s Danlos syndrome type IV,
and neurofibromatosis type 1
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Cigarette Smoking
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Most important risk factor
Double risk in former smokers compared to never smokers
Increased risk of multiple aneurysms
Increased size of aneurysms due to degradation of vessels walls
and increased dilation from increased blood pressure
HTN
 Chronic BP >160/95
 Risk of developing multiple aneurysms
 Poor outcome for untreated HT following SAH
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Heavy alcohol intake
 >150 g/week, 14 g of pure alcohol = 0.6 ounces
 Binge drinking
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Sympathomimetic drug use
 Cocaine in young SAH pts
 Increased risk of vasospasm with recent cocaine
use
 Increased risk of rupture and mortality
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BMI <23 is possible association
Diet
 Increased vegetable consumption, lower risk
 5 or more cups of caffeine/day possible risk
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Unruptured cerebral aneurysm depends on natural history
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Previous Hx
Family Hx
Age
Coexisting medical history
Aneurysm size, location, form and structure
Screening as prevention
 Not recommended if asymptomatic
 Cost vs. risk
▪ 2 studies showed cost benefit and improve QOL to screen pts with family Hx
 Low risk of recurrence for the first 5years after complete
disappearance
 Incomplete disappearance has increase risk at 3 days but rarely after 1
year
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Livesay, S., Wilson, S., Baumann, JJ.,
Hepburn, M., Brophy, G., Castle, A., Neyens,
R., Szabo, C., Garvin Higgins, P., Straw, M.,
Kelly, M. (2014). AANN Comprehensive Review
for Stroke Nursing. American Association of
Neuroscience Nurses